Medical shows sometimes showcase unusual physical findings that only one of a group of doctors realizes holds the key to a diagnosis. House is a wonderful example. What is not clear, perhaps, is the process by which really really smart (and some not so smart) medical students are tasked with learning how to examine the human body, methodically, while considering the problem to be solved and the clues waiting to be found.
There is a huge burden here: people who are sick enough to be in the hospital have already had several people ask a multitude of questions and physical exams performed. When all that is done, at a teaching hospital such patients are asked to put up with a doctor in training doing it all over again, but taking hours to do what the others did much more quickly (and usually, much less completely).
The burden can go both ways: As a third year student at Cedars Sinai hospital, I was tasked with taking the history and performing the physical on a man thought to have his appendicitis on the wrong side. I don’t recall if his surgery had already been performed but I do recall he was tired and it was getting late. I had reached the “social history” when he relayed that he had just divorced, “A Jap.” Just at that time, a code was called and I had to leave abruptly. I was angry that this man would use that word. I gave some thought on how to engage this on my return. Emergency dealt with, I woke him up —with some satisfaction—from a sound sleep to finish my assignment. He looked at me sleepily. “You were telling me that you just divorced a Japanese woman,” I started. He looked really confused and then burst out laughing, which if I recall, did cause him some abdominal pain. His reply: “No, I did not divorce a Japanese woman; I divorced a Jewish American Princess.”
For a wide variety of medical problems, most people getting physicals in the hospital setting do not have much to demonstrate to the student. For example, people with seizures or recovering from an overdose commonly look pretty normal on exam. The goal was to interact, get a good history (and there was a protocol developed in the last century for how detailed this should be), sort through the thought processes and list out all the medical and surgical diagnoses. The physical exam rarely added to the list of concerns. What students learn is the variety—infinite variety --of bodies and personalities inhabiting them.
A middle aged black woman required examination. Her eyes told me she saw me as a Doogie Houser but she was pleasant, unstressed, and forthcoming. History completed, I started the exam with the head first and contemplating the breast exam, she, sitting on the side of her bed suddenly exclaimed, “Oh, I have been meaning to get this looked at!” She dropped her gown off her shoulders and literally heaved a very large breast (macromastia) over her shoulder to demonstrate a “ditzel” (non-cancerous scaly skin lesion of unclear origin). I was frozen. At 24 yeas age, I had never seen a woman so casually heave a large breast about. Didn’t that hurt? How could it stay up there? She saw my face and laughed. We bonded. I duly reported in my assignment the presence of the skin lesion, the relative size of her breast, and the lack of any worrisome breast lumps……..
I suspect the chief medical doctor on a team, when assigned the responsibility of arranging for patients to accept this assignment with a medical student enjoyed trying to spice things up. A routine physical examination assignment found me at the Sepulveda VA where I was to obtain a history and physical. The attending doctor looked at the four of us and assigned a specific patient to me. The ward where I found the patient accommodated eight patients, all males, and the privacy in that ward was accomplished with a pull around cloth barrier. The patient was middle aged, and looked older than his age. We got acquainted and I learned the major points of his health history and his reason for being in the hospital: he was recovering from bypass surgery for his lower legs which had developed poor circulation after years of smoking. I proceded with the examination, starting at the head and giving feedback to him or asking clarifying questions as I moved down. I detected a stirring in the ward a I started to examine his genitals. As he dropped trou, before me, was a penis at half mast and which suffered from vitiligo (lack of pigment in the skin). He smirked and I thought I could hear giggling from the outer room. I completed the exam and asked some clarifying questions which fit his clinical picture—a presenting sign of hardening of the arteries in the lower extremities is impotence and for this, at some point, he had a semi erect penile implant placed (this was before the current “pump up” technology was available). I maintained my composure which given this setting, was no small thing. The patient asked for my number…….
Confronting the health hazards of being gay in the 1970’s Los Angeles area became evident without my being allowed to participate in an exam. On the surgical service, the group of residents and students (some six of us) were joined by the chief surgical resident on rounds. He was a magnificent doctor from Little Rock Arkansas which in West LA was awkward—Southern accents in high places were unusual—much more unusual than foreign accents. In any case, we gathered around the bed of a very ill appearing thin young man who had been diagnosed with peritonitis. As the patient was questioned, it was apparent that he was a young gay male prostitute who had had his colon ruptured when he was "fisted." The group of six doctors and students grappled with this unprofessionally as there were eye rolls, suppressed smirks, un-suppressed smirks, and the occasional stifled giggle. The chief resident sitting at the bedside suddenly looked up at us and was clear as only a Southern surgeon could be: “You all need to leave—now—I will complete this examination on my own." I will see you for afternoon rounds.” He later took the students aside to comment on professionalism and the scope of what we were likely to see in our lives and the need to maintain composure and a proper attitude for healing if we wanted to truly grow as doctors, not to mention, people. I took that to heart; it was a great experience and lesson on the very complicated process of teaching in a hospital that took all comers.
My OBGYN rotation my third year of medical school found me unhappy. While I loved the idea of caring for women and delivering babies, the residents doing that work were dysfunctional and not especially nice to their patients --or to me. One night, doing an OBGYN consultation in the ER, I tried out my Spanish on a young woman immigrant with pelvic pain. My attending was a brilliant but odd looking woman of middle age and a hairdo anticipating the singers from the B 52’s. In her white coat looking over my shoulder, she was imposing. I used my Spanish to reassure the patient and following protocol, explained what I was doing as I prepared to do the exam which was going to include cultures as a pelvic infection was high on the list of diagnoses. As I pulled the drape to allow visualization, I spread her legs and moved the stool in for a closer look. I was overwhelmed with a very strong foul odor. I maintained my composure and turned my head, breathing through my mouth and informed the attending physician that I thought we might have an anaerobic infection here (those like gangrene being famous for their foul odors). She had trouble maintaining her composure and I could not be sure why. I did the exam, discussing the findings as I went, got the cultures, and left the room to confer, asking the patient to put her clothes back on. The attending was sitting with a coffee and smiled saying, “Randy, there is no anaerobic infection. What you smelled was her feet, one on each side of you head………….
Again, at Cedars Sinai I was assigned doing the history and physical on a young woman admitted for mononucleosis (not unusual in 1972, especially if anorexia and hepatitis were present). I called in a nurse to help with the pelvic exam —which at Cedars, was done with a bedpan and a flashlight in the bed. This teenager had never had sex or a pelvic exam, was admitted for mononucleosis and this young student was going to do, what? The nurse, said politely, “You know, they do the pelvic exam to be thorough. You can say no thank you and not have it done.” I looked at the nurse with some puzzlement—such an intervention had never occurred. The relief on the patient’s face was to say the least, educational for me. I quickly thought about the implications of not doing a pelvic and realized that it was to say the least, superfluous for the care to be performed, and likely traumatic to the patient. I was actually glad the nurse spoke up. She was glad that I did not take offense or attempted to stick to the academic protocols that to that point, guided my life.
Her name was Kernie.
The lessons from such assignments were not forgotten . As an intern, I got a call from the chief resident who was moonlighting in the ER while I was on call. “I have an app for you to admit.” The admission of a case of appendicitis when on call was a reason for celebration as it usually meant that you got to go to the ER and often while watched by the surgeon, perform the actual appendectomy. I reviewed the history with the patient (in Spanish, when my proficiency was questionable) and did the physical exam slowly and methodically. I had just finished the abdominal exam when the chief resident came in the room. I pulled the drape down to perform the genital exam and we both saw, at the same moment, a greatly swollen left testicle—-which turned out to be the reason for his nausea and lower abdominal pain. The chief resident felt quite foolish, I felt like the cat that ate the canary, and yet another appendix eluded my grasp.
A fellow resident, Ken, was very much a big brother to me. He did not hover, gave me enough rope to hang myself when working with new problems but was always there to back me up and offer insights. His reputation soared when he diagnoses Leprosy while consulting in the ER. I thought Ken could do no wrong and was an encyclopedia of experience and medical knowledge. Years later, I learned that he did not come to the diagnosis in the fashion of Dr. House. He had no clue what the rash was, could not get much history, not speaking Spanish and being short on time with the translator. He did a diagnostic biopsy of the skin on a rash that could have been, in his words, “anything.” His systematic approach was what made the diagnosis, not any skill in teasing out a detailed history.
Towards the end of “physical diagnosis” exercises, my roommate Dwight and I teamed up to perform a mental health exam on a patient in the closed psychiatric unit. My recollection is that no physical was expected (people admitted to psychiatric units usually get very superficial physical exams for a variety reasons), and the exercise was to perform a mental health exam. This exam checks for orientation (date, place, time), appearance, dress, level of consciousness, perception, ability to abstract, and so on. Our patient was a disheveled very sad woman of Medicare age who was admitted after a suicide attempt. The, “Why are you here?” question identified her diagnosis of breast cancer, a mastectomy, and within months, her husband leaving her. She was profoundly depressed. Our discomfort with her life situation grew ever more difficult as we followed the protocol of the exam: “What do you think the expression, ‘a rolling stone gathers no moss,’ means?” Dwight and I made eye contact with each other and despite our compulsive natures with an assignment, we took what we had and abbreviated the exam to make a hasty retreat. We were overwhelmed by her situation. We had no life experience to help guide us with this assignment, but it certainly made us think about how to do it differently, next time.
Life experience, which helps in such cases, certainly did come with time.
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